A previously healthy 35-year-old woman comes to the physician due to daily headaches of 3 months duration. Her headaches are unilateral, throbbing, and associated with ipsilateral lacrimation and conjunctival injection. The headaches occur 6-10 times a day, and each lasts about 10 minutes. They are always at the same location in the left temporal region and are unpredictable. The patient has not had head or neck trauma, photophobia, phonophobia, nausea, vomiting, neck stiffness, fevers, or visual symptoms. She has been taking acetaminophen on an as-needed basis (

Question

A previously healthy 35-year-old woman comes to the physician due to daily headaches of 3 months duration.  Her headaches are unilateral, throbbing, and associated with ipsilateral lacrimation and conjunctival injection.  The headaches occur 6-10 times a day, and each lasts about 10 minutes.  They are always at the same location in the left temporal region and are unpredictable.  The patient has not had head or neck trauma, photophobia, phonophobia, nausea, vomiting, neck stiffness, fevers, or visual symptoms.  She has been taking acetaminophen on an as-needed basis (<3 days a week) without any improvement.  The patient has no other medical problems.
Her vital signs are within normal limits.  Neurologic examination is nonfocal.
An MRI of the brain reveals no abnormalities.  The patient is started on a trial of indomethacin 75 mg daily, and her headaches dramatically improve.
Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec193a_9874_9fce_853d_295c6f019fe6_MD0002_00 This patient likely has paroxysmal hemicrania, an episodic or chronic headache disorder. Patients typically have frequent episodes of unilateral throbbing head pain (>5 attacks a day) that usually last 2-30 minutes and are associated with autonomic features (ipsilateral lacrimation, conjunctival injection, and miosis). Improvement with indomethacin is a diagnostic criterion. An MRI of the brain is needed to rule out intracranial pathology. Paroxysmal hemicrania can turn into a chronic headache disorder known as chronic paroxysmal hemicrania (daily headache with pain-free periods) or hemicrania continua (daily headache without pain-free periods). Paroxysmal hemicrania, hemicrania continua, and cluster headache are considered trigeminal autonomic cephalalgias (characterized by unilateral trigeminal pain with associated ipsilateral autonomic findings). The main features of paroxysmal hemicranias that differentiate them from cluster headaches are higher frequency and shorter duration of attacks and response to treatment with indomethacin. Cluster headaches are more common in men, tend to follow a circadian rhythm, and can be triggered by small amounts of alcohol or nicotine (Choice A). Migrainous features (eg, photophobia, phonophobia, nausea) are usually absent in paroxysmal hemicrania; furthermore, migraine headaches almost always switch sides, often migrate, and typically last 4-72 hours (Choice C). (Choice B) Medication-overuse headache typically occurs after daily exposure (>15 days a month) to an analgesic medication (eg, acetaminophen, triptans, opiates) and is not associated with autonomic symptoms. (Choice E) Tension-type headaches are frequently bilateral with associated nonthrobbing and bandlike pain, but with no associated autonomic symptoms. Educational objective: Paroxysmal hemicrania presents as episodic or chronic unilateral throbbing head pain (usually lasting 2-30 minutes) associated with autonomic symptoms. Improvement with indomethacin confirms the diagnosis. Main features differentiating paroxysmal hemicranias from cluster headaches are the higher frequency and shorter duration of attacks and the response to indomethacin. __________ References: Indomethacin responsive headache syndromes: chronic paroxysmal hemicrania and Hemicrania continua. How they were discovered and what we have learned since. (http://www.ncbi.nlm.nih.gov/pubmed/20626997) Paroxysmal hemicrania: an update. (http://www.ncbi.nlm.nih.gov/pubmed/24523000)

A Previously Healthy 35-Year-Old Woman Comes to the Physician Due